Optimism: A Powerful Ally

Take a close look at that glass of water. Half empty? Half full? What you see could make a difference, not only in your daily health, but in how long you live. In one study, for example, researchers tracked 839 people over 30 years. In the 1960s, study participants took a standardized test to determine whether they were optimistic, pessimistic, or somewhere in between. Those who scored high on the pessimism scale turned out to have a 19% greater chance of premature death than those who scored more optimistically.

The Power of Optimism

“I believe we have compelling evidence that optimists and pessimists differ markedly in how long they will live,” says psychologist Martin Seligman of the University of Pennsylvania. “It is not clear if pessimism shortens life, optimism prolongs life, or both.”

Seligman says there are at least four ways that optimism can affect longevity. Optimists tend to:

• Be less passive than pessimists and less likely to develop learned helplessness or negative and debilitating responses to things that happen to them
• Be more likely to practice preventive health measures because they believe their actions make a difference
• Suffer depression at a markedly lower rate than pessimists (Depression is associated with mortality.)
• Have better functioning immune systems

The Bright Side

For decades, psychologists have studied the link between positive thinking and physical and mental health. According to Seligman, author of Learned Optimism: How to Change Your Mind and Your Life, it is more important to change negative thought patterns into positive ones than to worry about being optimistic. The picture of optimism he paints is not one of Pollyanna-like blindness to reality, but of a learned optimism grounded in accuracy and non-negative thinking.

Based on the results of several large-scale studies, Seligman discovered that optimists are more successful than pessimists. Optimistic politicians win more elections, optimistic students get better grades, optimistic athletes win more contests, and optimistic salespeople make more money.

Why would this be so? In his book Self-help Stuff That Works, Adam Kahn says it is “because optimism and pessimism both tend to be self-fulfilling prophecies. If you think a setback is permanent, why would you try to change it? Pessimistic explanations tend to make you feel defeated, making you less likely to take constructive action. Optimistic explanations, on the other hand, make you more likely to act. If you think the setback is only temporary, you are apt to try to do something about it.”

Optimist vs. Non-optimist

How can you determine whether you think more optimistically or pessimistically?

“I do not like to use the word pessimistic because most people would never consider themselves pessimistic,” says Khan, “But, many people are willing to admit they are not optimistic.”

Khan, like Seligman and other experts on motivation, defines optimists and non-optimists by how they explain events in their lives. Optimists see setbacks as specific, temporary, and changeable. Because of this, they are motivated to take action. Non-optimists tend to look at setbacks as general, permanent, and hopeless—symptoms of widespread failure that cannot be changed.

For example, an optimist who did not follow through on an exercise routine for a week might say, “I had a lot going on this week. I did not plan my time too well. I will have to do better next week.” A pessimist in the same situation might say, “I have no self-discipline. I obviously will not be able to meet my goals. Exercise just is not for me.”

A Matter of Degree

Dr. Pierce Howard, author of The Owner’s Manual for the Brain, contends that the line between optimism and pessimism is far from clear-cut.

“You are not just an optimist or a pessimist, it is a matter of degree,” Dr. Howard says. “You can be successful in life anywhere along the continuum.” He points out that pessimistic thinkers make great tax accountants, while optimists are more suited for careers in sales.

A Good Mood

Mood also has an influence on whether optimistic or pessimistic thoughts dominate your brain, according to Dr. Susan Vaughan, author of Half Empty, Half Full, a book that explores how gaining control over moods can result in more positive thinking.

“Mood is a powerful filter on how we see things,” maintains Vaughan, who sees most people as a blend of optimism and pessimism, depending on the situation.

She points to three methods optimistic people tend to use to lift their moods:

• Alternative thinking—When bad things happen, optimists tend to take them less personally and come up with multiple alternatives for why they might have happened, then work actively to fix the situation.
• Downward comparison—Though it sounds unkind, optimists compare themselves to others who are in worse situations as a way to brighten their own spirits.
• Relaxation—Optimists tend to use exercise, yoga, and even “putting on a happy face” as ways to relax and improve their moods.

Optimism: Not Always the Answer

Not everyone agrees that the solution lies in being optimistic. “The idea that optimists are healthier than pessimists is overly simplistic,” says Dr. Howard Friedman, a psychology professor at the University of California, Riverside. “Many times, excessive optimism can be harmful to one’s health. This is especially evident among teenagers, who take many risks.” Friedman contends it can be damaging to think optimistically when it comes to difficult health choices like quitting smoking, using condom, or wearing seatbelts. “I do not agree that in general we should try to make everyone more optimistic. There is absolutely no evidence that trying to do so will improve the general health of the population,” Friedman says.

A Better Strategy

Seligman concurs that there are times when it pays not to be optimistic, such as when planning for a risky future, when advising those with poor chances for the future, and when trying to be sympathetic to others’ problems. When the cost of failure is high, he advises, optimism is the wrong strategy.

Still, there are times when optimism can be a powerful ally. When achievement is the goal, use optimism. If trying to recover from depression. for example, optimistic thoughts can boost your morale.

Negative to Positive Thinking

Seligman argues that optimism, like other interpersonal skills, can be learned. “The way you explain setbacks to yourself is as much a habit as the way you tie your shoes,” agrees Khan. “It is no harder or easier to change a thought habit than it is to change a physical habit.” He recommends writing about setbacks and practicing arguing with your less optimistic thoughts until a more realistic vision of what has happened and what is likely to happen in the future emerges.

“It takes work, discipline, and focus,” Khan says. “But if you do not think you have these things, those are the first non-optimistic thoughts to tear apart.”

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RESOURCES:

American Counseling Association

Positive Psychology

CANADIAN RESOURCES:

Canadian Psychological Association

Healthy Canadians

REFERENCES:

Optimism and health. Harvard Medical School website. Available at: http://harvardpart…. Accessed May 1, 2008. Updated May 8, 2011.

Positive psychology. Martin Seligman Research Alliance at the University of Pennsylvania website. Available at: http://psych.upenn.edu/seligman/pospsy.htm .

Segerstrom S, Taylor S, Kemeny M, Fahey J. Optimism is associated with mood, coping and immune change in response to stress. APA PsycNET website. Available at: http://psycnet.apa…. Published June 1998. Accessed May 9, 2011.

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Can Folic Acid Help Ease Depression?

Folic acid (found in nature as folate), the B vitamin that is famous for its role in preventing birth defects, is being researched for its effects on depression.

A group of researchers from Tufts University in Boston, Massachusetts found that blood levels of folate were much lower among people with depression than in people who were not depressed. Findings like these have suggested a link between low folate levels and depression.

If low levels of this vitamin lead to depressive symptoms, it seems logical to conclude that giving folic acid supplements to people with depression will help their recovery. However, research shows that the connection is not that simple.

Folate in the Brain

Folate, which is needed to make DNA and RNA, the building blocks of cells, is quite active in the brain and central nervous system. It affects the production of certain essential compounds and neurotransmitters—substances that carry messages to different parts of the brain.

For example, folate deficiency leads to lower levels of S-adenosylmethionine (SAM) in the brain. Some research has suggested that supplementation with SAM can play a positive role in the treatment of depression. One possible theory is that low folate levels leads to low SAM, which increases symptoms of depression. By improving folate status, SAM increases, and depressive symptoms drop.

What the Studies Have Found

Some studies have found depressed patients to be deficient in folate, while others have shown no statistically significant differences in folate levels between people with and without depression. And when a link is found, it is unclear which came first—the deficiency or the depression.

Many depressed people tend to eat poor diets, which can lead to deficiencies of many vitamins and minerals, not just folate. Another possibility is that a third, unknown factor causes both folate deficiency and depression. However, there is a small amount of direct evidence to indicate that folate supplements might be helpful for depression.

A study in the Journal of Clinical Psychiatry found that sufficient amounts of folate are needed for the brain to work well. Deficiencies may cause a higher risk for depression and worsen the response to antidepressant medicine.

In a study published in the American Journal of Psychiatry, a group of researchers gave fluoxetine (Prozac) to 213 patients with major depressive disorder. The researchers also measured blood levels of folate in all study volunteers. After eight weeks on fluoxetine, the patients with low folate levels were significantly less likely to show improvement from the drug therapy.

Also, a study found that folic acid combined with fluoxetine was effective in the initial treatment of depression. However, this response was seen only in women; folic acid did not affect the men in the study. Researchers are not sure why only women responded, although it could have been that men needed a higher dose of folic acid.

Should Folic Acid Be Part of Depression Treatment?

Depression is a serious condition that requires careful, ongoing treatment with talk therapy, medicine, or a combination of the two. The research looking into folic acid and depression is still quite new. As the authors in an editorial in Psychotherapy and Psychosomatics explain, “Our understanding of the role of folate in mental disorders is still insufficient to make practical recommendations.” There are no clear guidelines for dosage or duration of treatment.

Other researchers argue that it is reasonable to ask your doctor about folic acid since it may be helpful when taking selective serotonin reuptake inhibitors (SSRIs). Also, the cost of the supplement is low.

The Bottom Line

If you are living with depression, talk with your doctor about folic acid. If you are deficient, your doctor may recommend taking a daily multi-vitamin and mineral supplement, as well as increasing your intake of foods rich in this vitamin. These include:

• Green leafy vegetables (like spinach and turnip greens)
• Legumes (black beans, lentils, peas, etc)
• Citrus fruits and juices
• Fortified cereals and grain products (including rice, pasta, bread, and certain breakfast cereals)

Note, however, do not take more than 400 micrograms daily of folic acid daily because a high intake may hide a vitamin B12 deficiency.

Keep in mind that a deficiency of folate might increase the risk of heart disease and stroke. In addition, for women considering pregnancy, sufficient folic acid intake can help decrease the risk of having a baby with a neural tube defect, such as spina bifida. Folic acid certainly is a vitamin worth getting your fair share of. It is just not yet clear if it can also help improve your mental state.

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RESOURCES:

Depression & Bipolar Support Alliance

National Alliance for the Mentally Ill

CANADIAN RESOURCES:

Canada’s Food Guide

REFERENCES:

Bjelland I, Useland PM, Vollset SE. Folate and depression [editorial]. Psychother and Psychosom . 2003;72:59-60.

Bottiglieri T, Laundy M, Crellin R, Toone BK, Carney MW, Reynolds EH. Homocysteine, folate, methylation, and monoamine metabolism in depression [abstract]. J Neurol Neurosurg Psychiatry . 2000;69:228-232.

Fava M, Borus JS, Alpert JE, Nierenberg AA, Rosenbaum JF, Bottiglieri T. Folate, vitamin B12, and homocysteine in major depressive disorder [abstract]. Am J Psychiatry . 1997;154:426-428.

Folate. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Accessed June 3, 2008.

Folate. EBSCO Natural and Alternative Treatments website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=114. Updated September 2009. Accessed April 29, 2010.

Mischoulon D, Raab MF. The role of folate in depression and dementia—review article. J Clin Psych. 2007;68(suppl):10:28-33.

Morris MS, Fava M, Jacques PF, Selhub J, Rosenberg IH. Depression and folate status in the US population [abstract]. Psychother and Psychosom . 2003;72:80-87.

Skerritt UM. A prevalence study of folate deficiency in a psychiatric in-patient population [abstract]. Acta Psychiatr Scand . 1998;97:28-232.

Tiemeier H, van Tuijl HR, Hofman A, Meijer J, Kiliaan AJ, Breteler MM. Vitamin B12, folate, and homocysteine in depression: the Rotterdam Study [abstract]. Am J Psychiatry . 2002;159:2099-2101.

Young SN, Ghadirian AM. Folic acid and psychopathology [abstract]. Prog Neuropsychopharmacol Biol Psychiatry . 1989;13:841-863.

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Is it “Just the Blues” or a More Serious Clinical Depression?

Depression is a serious medical condition involving your mood, thoughts, and body. It may affect how you feel about things, how you think about things, and how well you eat and sleep. Most people normally experience feelings of sadness, loss, or grief at different times throughout their lives. But depression is generally characterized by more intense feelings, such as hopelessness and worthlessness, and is persistent and recurring in nature.

By making the distinction between “the blues” and clinical depression, you can take the appropriate actions that may help improve your mood and quality of life. If you have depression, you will need professional medical treatment, since depression is not something that you can “shake off” on your own. On the other hand, if you have “the blues,” there may be a few things you can try to help improve your mood—but only after you are sure your symptoms are not a result of depression.

Symptoms of Depression

According to the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV), if five or more of the following symptoms persist for more than two weeks, or if they interfere with work or family life, you may be suffering from one of several different forms of clinical depression.

• Persistent sad, anxious, or “empty” mood
• Loss of interest or pleasure in activities, including sex
• Restlessness, irritability, or excessive crying
• Feelings of guilt, worthlessness, helplessness, hopelessness, pessimism
• Sleeping too much or too little, early-morning awakening
• Loss of appetite and/or weight loss or overeating and weight gain
• Decreased energy, fatigue, feeling “slowed down”
• Difficulty concentrating, remembering, or making decisions
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain
• Thoughts of death or suicide, or suicide attempts

Contact your healthcare provider or doctor for a complete evaluation, which will involve a physical checkup, a family health history, and a psychological evaluation.

Not everyone with depression experiences each of these symptoms. The intensity of the symptoms also varies from person to person.

If you are concerned that you may have depression, contact your healthcare provider or doctor regardless of which symptoms you have noticed. If you have thoughts of death or suicide, seek help immediately.

The Need for Treatment

Depression can be devastating and affect all areas of a person’s life, including personal relationships and the ability to work or go to school. Because of the false belief that you should be able to “get over” depression symptoms, some people with depression may not realize that they have a treatable disorder. Or they may be embarrassed or ashamed to seek treatment. However, receiving treatment for depression will not only improve your quality of life, but it may save your life as well. Untreated or inadequately treated depression may lead to suicide.

Types of Treatment

• Psychotherapy or counseling
• Prescription medications
• Combination of psychotherapy and medication

A variety of effective treatments are available to help people with depression. The main categories are antidepressant medications and psychotherapies (or counseling). Treatment is based on the form of depression and is individualized for each person. Some forms of depression may be treated with psychotherapy alone. Others require antidepressant drugs or a combination of drugs and counseling. Medications bring symptom relief and help correct any underlying deficiency of brain chemicals. Counseling can help you learn more effective ways to deal with depression and the factors that originally caused or triggered it.

The FDA advises that people taking antidepressants should be closely observed. For some, the medications have been linked to worsening symptoms and suicidal thoughts. These adverse effects are most common in young adults. The effects tend to occur at the beginning of treatment or when there is an increase or decrease in the dose. Although the warning is for all antidepressants, of most concern are the SSRI class such as:

• Prozac (fluoxetine), Zoloft ( sertraline), Paxil ( paroxetine), Luvox ( fluvoxamine), Celexa ( citalopram), Lexapro ( escitalopram)

For more information, please visit:  http://www.fda.gov/cder/drug/antidepressants/

Ways to Get Help

• If you need immediate help or if you are having thoughts of death or suicide, call the National Hopeline Network at 1-800-SUICIDE (1-800-784-2433).
• Talk to your healthcare provider or doctor about your symptoms and treatment options.
• Contact a hospital near your home to determine if they have or can recommend a mood/affective disorder clinic. If not, ask for their referrals to doctors in the community who specialize in the treatment of depression.
• If you, or someone you know, has been diagnosed with depression and treatment has not been effective within three months, get a second consultation. Preferably, this should be from a physician who specializes in the treatment of this illness.

Steps to Take for Managing “the Blues”

After you have checked with your doctor to be sure you do not have a more serious condition, such as depression, you may want to try a few of the following suggestions for managing your “blues:”

• Adjust your expectations. Set realistic goals you can achieve, breaking large tasks into smaller tasks to make them more manageable.
• Be patient with yourself. You may not be able to accomplish everything you usually do. Ask your friends and family for help when needed.
• Postpone important decisions until you are feeling more optimistic.
• Participate in activities that make you feel better, such as spending time with friends, making time for hobbies, traveling, and meditating.
• Increase your social and/or spiritual support.
• Reduce your stress.
• Exercise regularly.
• Eat a healthful diet.
• Consider attending a support group or talking with a counselor to help you come up with other strategies to improve your mood and functioning.

Be sure to visit iHerb.com to check out their selection of products for Depression and Anxiety Support.  Use Coupon Code WOW123 to get $5 off any first time order.

RESOURCES:

Depression and Bipolar Support Alliance

National Institutes of Mental Health

CANADIAN RESOURCES:

Canadian Mental Health Association

Mental Health Canada

REFERENCES:

American Psychiatric Association website. Available at: http://www.psych.org.

Antidepressant use in children, adolescents, and adults. US Food and Drug Administration website. Available at: http://www.fda.gov…. Published May 22, 2009. Accessed July 15, 2009.

National Institutes of Mental Health website. Available at: http://www.nimh.nih.gov/publicat/depressionmenu.cfm.

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Carnitine for Heart Health, Diabetic Neuropathy, COPD, Hyperthyroidism and Mild Depression Support

Carnitine is a substance used by the body uses to turn fat into energy. It is not normally considered an essential nutrient because the body can manufacture all it needs. However, supplemental carnitine could in theory improve the ability of certain tissues to produce energy. This has led to the use of carnitine for various muscle diseases as well as heart conditions.

Sources

There is no dietary requirement for carnitine. However, a few individuals have a genetic defect that hinders the body’s ability to make carnitine. In addition, diseases of the liver, kidneys, or brain may inhibit carnitine production. Certain medications, especially the antiseizure drugs valproic acid (Depakene) and phenytoin (Dilantin), may reduce carnitine levels; however, whether taking extra carnitine would be helpful has not been determined.^1-11 Heart muscle tissue, because of its high energy requirements, is particularly vulnerable to carnitine deficiency.

The principal dietary sources of carnitine are meat and dairy products, but to obtain therapeutic dosages a supplement is necessary.

Therapeutic Dosages

Typical adult dosages for the diseases described here range from 500 mg to 1,000 mg three times daily. For children, one study used 50 mg/kg twice daily, up to a maximum of 4 g daily.⁷³

Carnitine is taken in three forms: L-carnitine (for heart and other conditions), propionyl-L-carnitine (for heart conditions), and acetyl-L-carnitine (for Alzheimer’s disease). The dosage is the same for all three forms.

Therapeutic Uses

Carnitine is primarily used for heart-related conditions. Some evidence suggests that it can be used along with conventional treatment for angina to improve symptoms and reduce medication needs.^12-17 When combined with conventional therapy, it may or may not help prevent medical complications or sudden cardiac death in the months following a heart attack.^{18,19,34,36, 88}

Lesser evidence suggests that it may be helpful for a condition called intermittent claudication (pain in the legs after walking due to narrowing of the arteries),^20-30 as well as congestive heart failure.^12,31-33 In addition, a few studies suggest that carnitine may be useful for cardiomyopathy.^27,35

Carnitine may also be helpful for improving exercise tolerance in people with chronic pulmonary obstruction disease (COPD), more commonly known as emphysema.^37,38,39

Warning: You should not attempt to self-treat any of these serious medical conditions, nor should you use carnitine as a substitute for standard drugs.

Growing, if not entirely consistent, evidence suggests that L-carnitine or acetyl-L-carnitine, or their combination, may be helpful for improving sperm function and thereby provide benefits in male infertility.^{58-66,71, 80,86, 90-92,103}

Carnitine has also shown promise for improving male sexual function^81,82,93 and improving mental and physical fatigue in seniors.^81,87,108

Two studies found evidence that carnitine is helpful for Peyronie’s disease, a condition affecting the penis.^54,74

Some studies have found evidence that one particular form of carnitine, acetyl-L-carnitine, might be helpful in Alzheimer’s disease,^40-46 but the two most recent and largest studies found no benefit.^47,48 One review evaluated published and unpublished double-blind, placebo-controlled trials, and concluded that acetyl-L-carnitine may only be helpful for very mild Alzheimer’s disease.⁷⁰

In preliminary trials, acetyl-L-carnitine has shown some promise for treatment of depression or dysthymia (a milder condition related to depression).^{49,50, 94}

Some evidence suggests that carnitine may be useful for improving blood sugar control in people with type 2 (adult-onset) diabetes.^52,85 Better evidence suggests benefit with acetyl-L-carnitine for a major complication of diabetes, diabetic peripheral neuropathy (injury to nerves of the extremities caused by diabetes).⁸³ Acetyl-L-carnitine might help prevent diabetic cardiac autonomic neuropathy (injury to the nerves of the heart caused by diabetes).⁵³ However, one study found that carnitine supplements had an adverse effect on triglyceride levels in people with diabetes.⁸⁵

Much weaker evidence suggests possible benefits for neuropathy caused by the chemotherapy drugs cisplatin and paclitaxel.⁹⁵ Weak evidence hints that carnitine might help reduce liver and heart toxicity caused by the chemotherapy drug adriamycin.¹⁰⁴

Some evidence suggests that carnitine may be able to improve cholesterol profile.^18,84

One small study demonstrated a beneficial effect of L-carnitine on anemia and high cholesterol in patients on hemodialysis for chronic renal failure.¹⁰⁹

A genetic condition called fragile X syndrome can cause behavioral disturbances such as hyperactivity, along with intellectual disability, autism, and alterations in appearance. A preliminary study of 17 boys found that acetyl-L-carnitine might help to reduce hyperactive behavior associated with this condition.⁵¹ Evidence for the effectiveness of L-carnitine in attention deficit and hyperactivity disorder (ADHD) has been mixed.^73,111

Celiac disease is an autoimmune disease affecting the digestive tract. Fatigue is a common symptom of the disease. One small double-blind trial found evidence that use of L-carnitine at a dose of 2 g daily might help alleviate this symptom.¹⁰⁷ Weak evidence hints that carnitine may help people with degeneration of the cerebellum (the structure of the brain responsible for voluntary muscular movement).⁵⁵ One very small study suggests carnitine may be helpful for reducing symptoms of chronic fatigue syndrome.⁵⁶ Another study suggests that carnitine may be of value for treating hyperthyroidism⁵⁷ and for severe liver disease.⁹⁶ A substantial study marred by poor design (specifically, far too many primary endpoints) found equivocal evidence that L-carnitine, taken at dose of 500 mg three times daily, might be more effective than placebo for the treatment of fibromyalgia.¹⁰⁶

Other weak evidence suggests that carnitine may be helpful for decreasing the muscle toxicity of AZT (a drug used to treat HIV infection).^67,68 Other weak evidence hints that the acetyl-L-carnitine might reduce nerve-related side effects caused by HIV drugs in general.¹⁰⁵

One study failed to find carnitine effective for promoting weight loss,⁸⁸although another found that carnitine might lead to improvements in body composition (fat-muscle ratio).⁸⁷

Carnitine is widely touted as a physical sports performance enhancer, but there is no real evidence that it is effective and some research indicates that it is not.^69,97,110

Little to no evidence supports other claimed benefits such as treating irregular heartbeat, Down’s syndrome, muscular dystrophy, and alcoholic fatty liver disease. However, in a randomized trial involving 25 patients with liver cirrhosis and early brain dysfunction (hepatic encephalopathy) associated with severe forms of this condition, carnitine appeared to significantly improve the function of both the liver and the brain after 3 months of treatment.¹¹²

What Is the Scientific Evidence for Carnitine?

Angina

Carnitine might be a good addition to standard therapy for angina. In one controlled study, 200 individuals with angina (the exercise-induced variety) took either 2 g daily of L-carnitine or were left untreated. All the study participants continued to take their usual medication for angina. Those taking carnitine showed improvement in several measures of heart function, including a significantly greater ability to exercise without chest pain.¹² They were also able to reduce the dosages of some of their heart medications (under medical supervision) as their symptoms decreased.

Unfortunately, the results of this study can’t be fully trusted because researchers didn’t use a double-blind protocol. Another trial did use a double-blind, placebo-controlled, design tested L-carnitine in 52 people with angina and found evidence of benefit.¹⁶

In addition, several small studies (some of them double-blind) tested propionyl-L-carnitine for the treatment of angina, and also found evidence of benefit.^13-17

Intermittent Claudication

People with advanced hardening of the arteries, or atherosclerosis, often have difficulty walking due to lack of blood flow to the legs, a condition called intermittent claudication. Pain may develop after walking less than half a block. Although carnitine does not increase blood flow, it appears to improve the muscle’s ability to function under difficult circumstances.²⁶ A 12-month, double-blind, placebo-controlled trial of 485 patients with intermittent claudication evaluated the potential benefits of propionyl-L-carnitine.²⁹ Participants with relatively severe disease showed a 44% improvement in walking distance as compared to placebo. However, no improvement was seen in those with mild disease. Another double-blind study followed 245 people and also found benefit.²⁰

Similar results have been seen in most but not all other studies of L-carnitine or propionyl-L-carnitine.^21-28,30 Propionyl-L-carnitine may be more effective for intermittent claudication than plain carnitine.

Congestive Heart Failure

Several small studies have found that carnitine, often in the form of propionyl-L-carnitine, can improve symptoms of congestive heart failure.^12,31-33 In one trial, benefits were maintained for 60 days after treatment with carnitine was stopped.⁷⁹

After a Heart Attack

L-carnitine has shown inconsistent promise for use after a heart attack.

A double-blind, placebo-controlled study that followed 101 people for 1 month after a heart attack found that use of L-carnitine, in addition to standard care, reduced the size of the infarct (dead heart tissue).³⁴

In the months following a severe heart attack, the left ventricle of the heart often enlarges, and the pumping action of the heart becomes less efficient. Some evidence suggests that L-carnitine can help prevent heart enlargement, but that it does not improve heart function. In a 12-month, double-blind, placebo-controlled study of 472 individuals who had just undergone a heart attack, use of carnitine at a dose of 6 g/day significantly decreased the rate of heart enlargement.¹⁹ However, heart function was not significantly altered.

A 3-month, double-blind, placebo-controlled study of 60 individuals who had just undergone a heart attack also failed to find improvements in heart function.³⁶ (Heart enlargement was not studied.)

Results consistent with those of the studies above were seen in a 6-month double blind, placebo-controlled study of 2,330 people who had just had a heart attack.⁹⁸ Carnitine failed to produce significant reductions in mortality or heart failure (serious decline in heart function) over the 6-month period. However, the study did find reductions in early death. (Unfortunately, for statistical reasons, the meaningfulness of this last finding is questionable. Reduction in early death was a secondary endpoint rather than a primary one.)

Note: Carnitine is used along with conventional treatment, not as a substitute for it.

Diabetic Neuropathy

High levels of blood sugar can damage the nerves leading to the extremities, causing pain and numbness. This condition is called diabetic peripheral neuropathy. Nerve damage may also develop in the heart, a condition called cardiac autonomic neuropathy. Acetyl-L-carnitine has shown considerable promise for diabetic peripheral neuropathy and some promise for cardiac autonomic neuropathy.

Two 52-week double-blind, placebo-controlled studies, involving a total of 1,257 people with diabetic peripheral neuropathy, evaluated the potential benefits of ALC taken at 500 mg or 1000 mg daily.⁸³ The results showed that use of ALC, especially at the higher dose, improved sensory perception and decreased pain levels. In addition, the supplement appeared to promote nerve fiber regeneration.

A small study found some potential benefits for cardiac autonomic neuropathy.⁵³

Male Sexual Function

Carnitine has shown promise for improving male sexual function. One double-blind, placebo-controlled study of 120 subjects compared a combination of propionyl-L-carnitine (2 g per day) and acetyl-L-carnitine (2 g per day) against testosterone for the treatment of male aging symptoms (sexual dysfunction, depression, and fatigue).⁸¹ The results indicated that both testosterone and carnitine improved erectile function, mood, and fatigue, as compared to placebo. However, no improvements were seen in the placebo group. This is an unusual occurrence in studies of erectile dysfunction, so it casts some doubt on the study results.

A double-blind study of 40 men evaluated propionyl-L-carnitine (2 g per day) in diabetic men with erectile dysfunction who had not responded well to Viagra.⁸² The results indicated that carnitine significantly enhanced the effectiveness of Viagra.

In another double-blind study, a combination of the propionyl and acetyl forms of carnitine enhanced the effectiveness of Viagra in men who suffered from erectile dysfunction caused by prostate surgery.⁹⁹

Male Infertility

Growing evidence suggests that L-carnitine or acetyl-L-carnitine or their combination may be helpful for improving sperm quality and function, thereby benefiting male infertility.^{58-66,71,80,100-101,103}

For example, in one double-blind, placebo-controlled study of 60 men, use of combined L-carnitine (2 g per day) and acetyl-L-carnitine (also at 2 g per day) significantly improved sperm quality.⁸⁰

Chronic Obstructive Pulmonary Disease (COPD)

Evidence from three double-blind, placebo-controlled studies enrolling a total of 49 people suggests that L-carnitine can improve exercise tolerance in COPD, presumably by improving muscular efficiency in the lungs and other muscles.^37-39

Alzheimer’s Disease

Numerous double- or single-blind studies involving a total of more than 1,400 people have evaluated the potential benefits of acetyl-L-carnitine in the treatment of Alzheimer’s disease and other forms of dementia.^40-48,76-78 However, while early studies found evidence of modest benefit, two large and well-designed studies failed to find acetyl-L-carnitine effective at all.

The first of these was a double-blind, placebo-controlled trial that enrolled 431 participants for 1 year.⁴⁷ Overall, acetyl-L-carnitine proved no better than placebo. However, because a close look at the data indicated that the supplement might help people who develop Alzheimer’s disease at an unusually young age, researchers performed a follow-up trial. This 1-year, double-blind, placebo-controlled trial evaluated acetyl-L-carnitine in 229 patients with early onset Alzheimer’s.⁸ Unfortunately, no benefits were seen here either.

One review of the literature concluded that acetyl-L-carnitine may be helpful for mild cases of Alzheimer’s disease, but not more severe cases.⁷²

Mild Depression

A double-blind study of 60 seniors with dysthymia (a mild form of depression) found that treatment with 3 g of carnitine daily over a 2-month period significantly improved symptoms as compared to placebo.⁴⁹ Positive results were seen in two other studies as well, one of depression and one of dysthymia.^{50, 102}

Hyperthyroidism

Enlargement of the thyroid (goiter) can be due to many causes, including cancer and iodine deficiency. In some cases, thyroid enlargement occurs without any known cause, so-called benign goiter.

Treatment of benign goiter generally consists of taking thyroid hormone pills. This causes the thyroid gland to become less active, and the goiter shrinks. However, there may be undesirable effects as well. Symptoms of hyperthyroidism (too much thyroid hormone) can develop, including heart palpitations, nervousness, weight loss, and bone breakdown.

A double-blind, placebo-controlled trial found evidence that use of L-carnitine could alleviate many of these symptoms. This 6-month study evaluated the effects of L-carnitine in 50 women who were taking thyroid hormone for benign goiter.⁵⁷ The results showed that a dose of 2 g or 4 g of carnitine daily protected participants’ bones and reduced other symptoms of hyperthyroidism.

Carnitine is thought to affect thyroid hormone by blocking its action in cells.⁷⁵ This suggests a potential concern—carnitine might be harmful for people who have low or borderline thyroid levels to begin with. This possibility has not been well explored as yet.

Peyronie’s Disease

Peyronie’s disease is an inflammatory condition of the penis that develops in stages. In the first stage, penile pain occurs with erection; next, the penis becomes curved; finally, erectile dysfunction may occur. Many medications have been tried for Peyronie’s disease, with some success. One such drug is tamoxifen, which is better known as a treatment to prevent breast cancer recurrence. A 3-month, double-blind study compared the effectiveness of acetyl-L-carnitine to the drug tamoxifen in 48 men with Peyronie’s disease.⁷⁴ Acetyl-L-carnitine (at a dose of 1 g daily) reduced penile curvature while tamoxifen did not; in addition, the supplement reduced pain and slowed disease progression to a greater extent than tamoxifen.

Safety Issues

L-carnitine in its three forms appears to be quite safe. However, individuals with low or borderline-low thyroid levels should avoid carnitine because it might impair the action of thyroid hormone.75

Individuals on dialysis should not receive this (or any other supplement) without a physician’s supervision.

The maximum safe dosages for young children, pregnant or nursing women, or those with severe liver or kidney disease have not been established.

Interactions You Should Know About

If you are taking:

• Antiseizure medications, particularly valproic acid (Depakote, Depakene) but also phenytoin (Dilantin): You may need extra carnitine.
• Thyroid medication: Do not take carnitine except under a physician’s supervision.

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Click here to review the References for this article at the iHerb Health Library.

The Role of Depression in Heart Disease

“Everybody obviously has a mood dip after a heart attack,” says Laura Kubzansky, PhD, MPH, an assistant professor of society, human development, and health at Harvard University. But in studies, she says, heart attack victims diagnosed with medical depression fared significantly worse than heart attack victims without signs of depression. Interestingly, these studies suggest that many of these depressed patients were never depressed or treated for depression before they had heart attacks.

Several medical studies, says Kubzansky, have tracked heart attack patients for many months after they left the hospital. The studies found that the patients with diagnosable depression suffered more heart complications including death.

Identifying the Risk Factors for Heart Disease

In the United States, heart disease is the number one killer of men and women. To help determine who may need more aggressive treatment after a heart attack, physicians assess each patient’s risk factors. Most known risk factors center around complications of the heart itself or predisposing traits like high cholesterol, smoking, diabetes or hypertension. Interest in the role of depression and mental health, however, opens up another avenue in the fight against heart disease and its complications. In light of findings of depression as a risk factor, many doctors now recommend that all heart attack patients be screened for depression.

Finding the Connection

To understand why depression in heart attack patients may lead to worse complications, doctors look for common biologic patterns that connect the two. The current prevailing theory focuses on the balance of the actions of the nervous system. Part of the nervous system, called the autonomic nervous system, constantly regulates our internal organs without our awareness.

For example, we don’t need to tell our lungs to breathe or our hearts to beat. The autonomic nervous system does these things on its own. But if the autonomic nervous system is off-balance, many normal functions of the body are affected. Scientists note that patients with depression have distinctive changes in the balance of their autonomic nervous systems. Some believe these changes may underlie the connection between depression and heart disease.

If there is a biologic connection between depression and heart disease in people with weakened hearts, can depression also be a risk factor for heart disease in people with normal hearts? According to a medical review, this does indeed seem to be the case.

Treating Depression Effectively

For some heart attack patients, symptoms of depression may resolve without treatment. For others, whose symptoms persist, data sheds light on effective treatment. A large medical study showed that the antidepressant sertraline (Zoloft) causes no harm to the heart and can reduce symptoms of depression in people with heart disease.

Another large study of heart patients with depression, however, found that patients treated with psychotherapy had the same rate of heart complications as their counterparts who did not get psychotherapy. But patients in this study who took antidepressant medications seemed to do a little better. The investigators call for further research to determine the best way to treat depression and reduce complications in heart attack patients.

In sum, any patient who has suffered a heart attack should discuss the risks of depression with their doctor. Likewise, patients with depression and no evidence of heart disease should be aware of all heart disease risk factors and should evaluate their individual risks with their physicians.

Click here to see iHerb’s selection of  products for Depression Support and here for Heart Support Products! New to iHerb? Use Coupon Code WOW123 to get $5 off any first time order.

RESOURCES:

American Heart Association

Family Doctor

CANADIAN RESOURCES:

Canadian Cardiovascular Society

REFERENCES:

Berkman LF, Blumenthal J, Burg M, et al. Enhancing recovery in coronary heart disease patients investigators (ENRICHD). Effects of treating depression and low perceived social support on clinical events after myocardial infarction. The enhancing recovery in coronary heart disease patients (ENRICHD) randomized trial. JAMA. 2003;289:3106-3116.

Carney RM, Blumenthal JA, Stein PK, et al. Depression, heart rate variability, and acute myocardial infarction. Circulation. 2001;104:2024-2028.

Carney RM, Freedland KE, Miller GE, et al. Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms [Abstract]. J Psychosom Res. 2002;53:897-902.

Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation. 1995;91;999-1005.

Glassman AH, O’Connor CM, Califf RM, et al. Sertraline antidepressant heart attack randomized trial (SADHEART) Group. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288(6):701-9.

Heart attack and angina statistic. American Heart Association website. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4591 . Accessed April 15, 2008.

Heart disease and stroke statistics—2003 update. American Heart Association website. Available at: http://www.americanheart.org. Accessed August 20, 2003.

Lauzon C, Beck CA, Huynh T, et al. Depression and prognosis following hospital admission because of acute myocardial infarction. CMAJ. 2003;168:547-552.

Wulsin LR, Singal BM. Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review. Psychosom Med. 2003;65:201-210.

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How to Choose a Therapist or Counselor

Perhaps you have a chronic or difficult problem, or maybe you feel depressed or sad. Before you jump into therapy, there are important issues that you need to consider. For example, “How do I choose a therapist?” “How much will it cost and how long will it take?” “What kinds of therapies are there and how do they differ?” ” What should I expect at my first session?”

What to Look For

Your therapist is a counselor—not your friend. But it is important that you choose someone that respects your opinion, your input, and your individuality. Susan James, PhD, a clinical psychologist at the University of Chicago, says that one of the most important things to consider when entering a therapeutic relationship is whether the values of the therapist match your values.

“Are you being encouraged to behave in ways that make you feel comfortable or uncomfortable? Is your therapist able to talk with you about all of the important dimensions of your life such as religious beliefs and lifestyle?” Mismatches, Dr. James says, can occur when the client and therapist have different value systems or when there are misunderstandings about the level of conversational intimacy. Engaging the right therapist—someone with whom you are comfortable and trust—is important in ensuring that you get the best treatment possible.

Where to Find a Therapist

Look for recommendations from your doctor or other healthcare providers, professional organizations, or friends. Health care professionals can also separate your physical problems from emotional ones. Laura M. went for a physical checkup when her anxiety over moving to a new city and the birth of her second child made her irritable and chronically fatigued.

Her primary care physician could find no physical difficulties, and instead recommended that she talk with someone about her concerns.

“Although I didn’t know my primary care physician well,” Laura says, “he had an excellent grasp of my problems and talked about it in a way that made sense to me. The therapist he recommended also seemed to understand my issues and was able to help me without putting me on any sort of medication.”

How Much It Will Cost and How Long It Will Take

Therapy can be costly. Cost will be based in part on the reputation and educational background of the therapist, his or her institutional affiliation, and geographic location. Your therapist will usually ask you at the first session how you intend to pay for his or her services, so it is smart to check with your insurance provider to know exactly how much of your treatment will be covered.

The length of therapy can vary widely depending on your particular issues and your background. Treatment for mild or situational problems can be relatively short and might be accomplished in as few as five or six sessions. Chronic problems and long-term difficulties, however, may require a year or more before you feel that progress is being made. One way to monitor your progress is to formalize (in writing) a set of treatment goals. This ensures that both you and your therapist are working on the same issues and helps you assess the benefits for yourself.

When it comes time to end therapy, your therapist may encourage you to discuss your decision, but a good therapist should always respect your judgment about when it is time to go it on your own. Although the cost of therapy can affect the way you approach the process and what therapist you choose, the length of treatment should be based on more important factors.

What the Options Are

It is difficult to make choices when you are in a state of near-panic. But most of us have a sense of when things are starting to spiral out of control. That is the time to consider the different approaches that various therapists take to healing. There are a number of different theories at the foundation of clinical practice. These theories help a clinician think about your problems and how to treat them.

Therapies are generally divided into the following approaches:

• Behavioral therapy—This type of therapy looks to replace harmful behaviors with useful ones. It is often used in coordination with cognitive therapy, which is aimed at helping people recognize and alter distorted ways of thinking.
• Humanistic and experiential therapies—These therapies are based on the theory that people are growing and self-actualizing. Experiential therapists use emotionally-charged, experience-based techniques to effect change, while humanistic therapists concentrate on creating a safe place for the patient.
• Psychoanalytic and psychodynamic therapies—These therapies explore unconscious conflicts and defense mechanisms that hinder adult behavior.
• Family therapy or family systems therapy—This type of therapy is concerned with looking at the dynamics of relationships within the family unit.
• Marriage and family therapy—There are certain patterns of behavior, conflicts, or dynamics that are characteristic to specific families or couples. These patterns will be addressed in therapy and worked on through the therapeutic process and its goals. The most important factor is the “set of relationships” that couples or family members are part of.
• There are also different categories of mental health professionals:
• Psychiatrists—physicians who have completed medical school, and a residency in psychiatry. They are the only mental health professionals licensed to prescribe medicines
• Psychoanalysts—therapists with a professional degree in psychiatry, psychology, or social work, plus extensive supervised training
• Psychologists (PhD, DPsy, DEd)—licensed professionals who have typically completed a clinical internship
• Certified or licensed social workers—therapists who have a master’s degree and two years of supervised, postgraduate experience

Marriage and family therapists may have a master’s or doctorate degree as well as supervised experience in the field. Note that while psychoanalysts are usually only trained in psychoanalysis, psychologists and social workers usually have training in several of the therapies discussed above.

What to Expect at the First Appointment

Your first session, sometimes called an intake evaluation, will be unlike subsequent sessions. This is a time for your therapist to get to know you—what is important to you and what particular problems or difficulties have brought you into therapy. You will be asked about your family history and childhood, education, friends and social relationships, career, romantic relationships, and current living situation. The depth of this personal history will vary depending on your therapist and his or her particular theoretical orientation. Once the therapist has developed some understanding of you, he or she will ask if you have any questions. This is the time to raise questions you have about the therapist’s training and theoretical orientation and experience with treating problems similar to your own.

Be aware that subsequent sessions may be complex. Facing what appears to be a singular issue can often veer off into many other directions. You may need to delve into areas of your life that you had not anticipated exploring.

What to Do If You Don’t Like Your Therapist

You do yourself a disservice by staying with a therapist that you do not like. If you feel that your therapist is not listening to you, or is downplaying your problems, or has a value system that differs from your own, do not hesitate to talk about it. A responsible therapist has an obligation to either work it out to your satisfaction or to refer you to someone else. Use the same consumer-wise techniques you apply to consumer goods when you “purchase” your therapy. Make sure you get what you need from the best person available.

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RESOURCES:

American Association for Marriage and Family Therapy

American Counseling Association

CANADIAN RESOURCES:

Canadian Psychiatric Association

Canadian Psychological Association

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Causes, Symptoms and Treatment of Seasonal Affective Disorder

Many people have difficulty dealing with the darker, shorter days of winter. They struggle to get out of bed in the morning, have less energy, feel down, and gain weight. For people with seasonal affective disorder (SAD), these changes are severe enough to cause significant problems in their everyday lives. But what exactly is SAD? How does it differ from the “winter blues” and normal sadness? And how can it be treated?

What Is Seasonal Affective Disorder?

SAD is a type of depression that occurs due to a lack of exposure to light during the winter. It usually begins in the fall (October or November) and subsides in the spring (March or April). The onset and severity of the symptoms are highly individualized and depend, in part, on where you live.

The number of cases and severity of symptoms increase with distance from the equator. For example, people near the Arctic Circle tend to experience more severe SAD starting earlier in the fall than people in the Caribbean. A true SAD diagnosis can be made only after symptoms have lasted over the past two winters for at least four weeks each time.

The symptoms of SAD can range from mild to severe. They may simply be a nuisance to live with or severe enough to affect your ability to function. People who experience mild symptoms but aren’t diagnosed with SAD are often described as having the “winter blues” or “subsyndromal SAD.” Three to five percent of Americans have SAD and about another 10% have subsyndromal SAD.

Women experience SAD three to four times more often than men. This disorder affects people of any racial or ethnic group, and it can occur at any age—though it is mostly seen in people in their twenties through forties. Even children can be affected by SAD; however, they may experience different symptoms than adults. For example, children are more likely to be irritable instead of sad or anxious.

Common Symptoms of Seasonal Affective Disorder

The following symptoms typically begin in the fall, intensify in winter, and subside in spring:

• Decreased energy and activity
• Tiredness, sleep more
• Sadness, anxiety
• Appetite changes (usually increased appetite)
• Carbohydrate craving
• Weight gain
• Loss of interest in sex
• Withdrawal from friends and family
• Difficulty concentrating and accomplishing tasks
• Premenstrual syndrome in women (worsens or only occurs in winter)

How Does SAD Differ From Other Types of Depression?

The main difference between SAD and other types of depression is that SAD occurs only during the winter months. In many types of depression, people generally eat and sleep less and lose weight; people with SAD usually eat and sleep more and gain weight when it is cold and dark outside.

SAD, like other types of clinical depression, is not caused by psychological or social factors, although such stresses can aggravate it. Normal sadness tends to be situational and does not generally include these physical symptoms.

The “holiday blues” can be distinguished from SAD because they are generally not accompanied by physical symptoms. They are caused by the typical stresses of the December holiday season and occur only around the holidays.

What Causes SAD?

Lack of exposure to light seems to be the main trigger of SAD symptoms. There are a variety of hypotheses as to the underlying biochemical process that is affected by the lack of light. Also, SAD appears to run in families. Most people with the disorder have at least one close relative who has had bouts of depression (often SAD) at some time.

An abnormality in one or more neurotransmitters and/or hormones is the suspected cause of SAD. Neurotransmitters are the chemicals that carry messages between nerve cells. A deficiency of the neurotransmitter serotonin is considered to be a likely cause of SAD. Its concentration in the brain varies with the seasons, the smallest amount occurring during the winter.

Other chemicals under investigation include the neurotransmitters norepinephrine and dopamine, and the hormone melatonin. The female sex hormones estrogen and progesterone may also be involved, since women are more vulnerable to SAD than men—especially in the years between puberty and menopause.

How Can SAD Be Treated?

Light Therapy

Light therapy is the primary treatment for SAD. In some studies, light relieves symptoms in 75% of SAD patients within 2-14 days. Scientists believe that light entering through the eye may modify brain chemistry, correcting the abnormalities resulting from a lack of light. While light therapy almost certainly works, only a relatively small number of studies have been rigorous enough to offer scientific proof of light therapy’s effectiveness.

In this treatment, a person is exposed to light that is 5-20 times brighter than regular indoor lighting by sitting close to a light box for 15 minutes to a few hours a day. Since looking directly at the light is not recommended, usual activities such as reading, writing, and eating can be carried out. The length of time and intensity of the light can vary depending on a person’s needs and the equipment used. Initial evaluation and ongoing supervision of treatment should be provided by a healthcare professional who has experience with light therapy.

Although light therapy is safe for most people, it can cause eyestrain, headaches, insomnia, and feelings of restlessness or irritability. These problems can often be resolved by reducing the length of exposure or sitting farther from the light box. People with certain types of eye disease or those taking medications that increase light sensitivity may not be able to use light therapy, or should use it only under closely monitored care from an ophthalmologist.

Lifestyle Changes

Although light therapy is considered the first-line treatment for most people with SAD, there are lifestyle changes you can try instead of, or in conjunction with, light therapy. Some people experience improvement from increasing their exposure to indoor light from regular lamps and to outdoor light by taking daily walks during the morning or afternoon. Taking a winter vacation in a sunny place with longer days may also help.

Getting regular aerobic exercise can also help improve mood in people with SAD. Its effect is enhanced when done outdoors or in front of a light box. In addition, exercise and diet can be used to control the weight gain common in SAD. Since stress can exacerbate SAD, stress management is important, especially during the winter months. Psychotherapy may be useful in coping with problems that are causing stress.

Medications

Antidepressant medications can be used to treat SAD, but are usually prescribed with light therapy instead of replacing it altogether. When light therapy is only partially successful, medication may enhance the light’s effect. Use of light therapy in conjunction with medication may make it possible to take smaller doses of medication and to reduce medication side effects. In addition, taking medication can decrease the amount of time that is needed in front of lights.

The most frequently used antidepressant medications for SAD are the selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Zoloft, and Paxil. Bupropion (Wellbutrin) and other antidepressants may also be effective. Bupropion can be prescribed for the prevention of major depressive episodes in patients with a history of SAD.

Research Results

The Can-SAD study was a double-blind, randomized, controlled study performed during three winter seasons in several treatment centers in Canada. The study was scientifically designed to meet the rigor of statistical standards.

Ninety-six patients were randomly assigned for the length of eight weeks to one of the following treatment groups: an intense light treatment and placebo medication, or a placebo (very low intensity) light and medication (Fluoxetine). There were no statistically significant differences between the two modalities of treatment, which basically “supports the effectiveness and tolerability of both treatments for seasonal affective disorders.”

Rohan et al performed the first controlled psychotherapy trial for SAD. They compared standard light therapy (LT), SAD goal-oriented cognitive behavioral therapy (CBT), and their combination with delayed LT control (which is LT after 6 weeks of monitoring the patients clinically). For the three modalities of treatment, the results showed “significant reductions in depressive symptoms.” Rohan et al recommended that more research needs to be done in this area.

Other treatments with possible benefit are still being investigated. These include melatonin, L-tryptophan, and vitamin d supplementation.

What Is the First Step in Treating SAD?

If you have mild SAD symptoms, start by increasing your exposure to regular indoor and outdoor light. Try starting a walking program or a daily exercise regime. If you have symptoms that are significantly interfering with your quality of life, you should consult your healthcare provider and/or a mental health professional. He or she can determine whether you do have SAD and discuss available treatments. Remember, there are a number of different treatment options that can be used alone or in combination that can help you feel better and keep a brighter outlook on winter.

Looking for vitamins, herbal supplements and other alternatives to help you keep a healthy balance in your life? Check out the 19,000 products we sell at iHerb.com. Use Coupon Code WOW123 to get  you $5 off any first time order.

RESOURCES:

National Institute of Mental Health

The Society for Light Treatment and Biological Rhythms

CANADIAN RESOURCES:

Canadian Psychiatric Association

Canadian Psychological Association

REFERENCES:

Anderson JL, Weiner GI. Seasonal depression. Harvard Health Letter. 1996;21:7.

Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 2005;162:656-662.

Information sheet on seasonal affective disorder and light therapy. National Institute of Mental Health, Clinical Psychobiology Branch. Bethesda, MD; August 1996.

Lam RW, Levitt AJ, Levitan RD, et al. The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. American Journal of Psychiatry. 2006;163:805-812.

National Institute of Mental Health website. Available at: http://www.nimh.nih.gov .

The National Organization for Seasonal Affective Disorder (NOSAD) website. Available at: http://www.nosad.org.

Public information brochure: questions and answers about light therapy. Society for Light Treatment and Biological Rhythms. Wheat Ridge, CO.

Rohan KJ, Roecklein KA, Tierney LK, Lacy TJ. A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder. Journal Consult Clin Psychol. 2007;75:489-500.

Rosenthal NE. Diagnosis and treatment of seasonal affective disorder. JAMA. 1993;270:2717-2720.

Seasonal affective disorder. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated February 9, 2009. Accessed March 21, 2009.

The Society for Light Treatment and Biological Rhythms website. Available at: http://www.sltbr.org.

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Fish Oil May Be Helpful Towards Cholesterol, Depression, Rheumatoid Arthritis Support and More!

Fish oil contains omega-3 fatty acids, one of the two main classes of essential fatty acids. ( Omega-6 fatty acids are the other main type.) Essential fatty acids are special fats that the body needs for optimum health.

Interest in the potential therapeutic benefits of omega-3 fatty acids began when studies of the Inuit (Eskimo) people found that, although their diets contain an enormous amount of fat from fish, seals, and whales, they seldom suffer heart attacks. This is presumably because those sources of fat are very high in omega-3 fatty acids.

Subsequent investigation found that the omega-3 fatty acids found in fish oil have various effects that tend to reduce risk of heart disease and strokes. However, research into whether use of fish oil actually prevents these diseases, while somewhat positive, remains incomplete and somewhat inconsistent. In recognition of this, the FDA has allowed supplements containing fish oil or its constituents to carry a label that states: “Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may reduce the risk of coronary heart disease.”

In addition, a slightly modified form of fish oil (ethyl-omega-3 fatty acids) has been approved by the FDA as a treatment for hypertriglyceridemia (high triglycerides).²³⁷ This specially processed product, sold under the trade name Omacor, is widely advertised as more effective than ordinary fish oil. However, it should be noted that Omacor has undergone relatively little study itself; the physician prescribing information notes only two small trials to support its effectiveness for this use. This is a far lower level of evidence than usually required for drug approval and also substantially lower than the body of evidence supporting standard fish oil as a treatment for high triglycerides.

Fish oil has also shown promise as an anti-inflammatory treatment for conditions such as rheumatoid arthritis, menstrual pain, and lupus. In addition, it may be helpful for various psychiatric conditions.

Requirements/Sources

There is no daily requirement for fish oil. However, a healthy diet should provide at least 5 g of essential fatty acids daily.

Many grains, fruits, vegetables, sea vegetables, and vegetable oils contain significant amounts of essential omega-6 and/or omega-3 fatty acids, but oil from cold-water fish is the richest natural source of omega-3 fats. It is commonly stated that people require a certain optimum ratio of omega-3 to omega-6 fatty acids in the diet; however, there is no real evidence that this is true, and some evidence that it is false.²³¹

Therapeutic Dosages

Typical dosages of fish oil are 3 g to 9 g daily, but this is not the upper limit. In one study, participants ingested 60 g daily.

The most important omega-3 fatty acids found in fish oil are called eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). In order to match the dosage used in several major studies, you should take enough fish oil to supply about 2 g to 3 g of EPA (2,000 mg to 3,500 mg) and about 1.0 g to 2.5 g of DHA daily (1,000 mg to 2,500 mg). Far higher doses have been used in some studies; conversely, one study found blood-pressure lowering effects with a very low daily dosage of DHA—0.7 g.²³⁸

DHA and EPA are not identical and might not have identical effects. Some evidence hints that DHA may be more effective than EPA for thinning the blood ¹⁷⁶ and reducing blood pressure.¹⁰⁵ The reverse may be true for reducing triglyceride levels, but study results are conflicting.^{160-165, 235}

Some manufacturers add vitamin E to fish oil capsules to keep the oil from becoming rancid. Another method is to remove all the oxygen from the capsule.

If possible, purchase fish oil products certified as free of significant levels of mercury, toxic organochlorines, and PCBs (see Safety Issues).

Flaxseed oil also contains omega-3 fatty acids, although of a different kind. It has been suggested as a less smelly substitute for fish oil. However, it is far from clear whether flaxseed oil is therapeutically equivalent to fish oil.^1,200

Therapeutic Uses

Consumption of fish oil alters the body’s production of certain substances in the class of chemicals called prostaglandins. Some prostaglandins increase inflammation while others decrease it. The prostaglandins whose production is enhanced by fish oil fall into the anti-inflammatory category. Based on this, fish oil has been tried as a treatment for early stages of rheumatoid arthritis, with positive results. It is thought to significantly reduce symptoms without causing side effects and may magnify the benefits of standard arthritis drugs.^37,38,179 However, while some standard medications can slow the progression of the disease, there is no evidence that fish oil can do this. Much weaker evidence hints that fish oil might be helpful for the related disease ankylosing spondylitis.²³²

Fish oil’s apparent anti-inflammatory properties are the likely explanation for its apparent benefit in dysmenorrhea (menstrual pain), as seen in two studies.^39,40 Similarly, fish oil may be helpful for the autoimmune disease lupus.^137,191 (However, two studies failed to find fish oil helpful for kidney disease caused by lupus.^138,139) Evidence has been mixed regarding whether fish oil is beneficial for Crohn’s disease or ulcerative colitis, conditions in which parts of the digestive tract are highly inflamed.^{49-51,61-68, 159,201} More recently, however, two well-designed trials enrolling a total of 738 patients convincingly failed to find any benefit for omega-3 fatty acid supplementations in the prevention of Crohn’s disease relapse.²⁵⁴

Incomplete evidence hints but does not prove that fish or fish oil might help prevent death caused by heart disease.^152,202 This effect seems to result from several separate actions. The best documented involves reducing high triglyceride levels; studies enrolling more than 2,000 people have substantiated this use.1 In addition, fish oil might raise HDL (“good”) cholesterol levels, “thin” the blood, lower levels of homocysteine, prevent dangerous heart arrhythmias, slow heart rate, improve blood vessel tone, and decrease blood pressure. ^{14,15,51,90-94,96-105,151,160-165,174,177,189,190,203-204,238} These effects also support findings that fish oil may help prevent strokes.^20,178 However, results are conflicting on whether people with angina should take fish oil or increase intake of fatty fish; one large study actually found that fish oil increased risk of sudden death.²⁰⁶

For a number of theoretical reasons, it has been suggested that fish oil and its constituents (especially a slightly modified form of EPA called ethyl-EPA) might have positive effects on various psychiatric disorders, most notably depression. However, there is no convincing evidence that low levels of omega-3 fatty acids in the bloodstream leads to even mild depression.²⁵⁹ Moreover, larger trials have generally failed to demonstrate a beneficial effect of fish oil-related products in depressed patients.^{154,168,188,192,193,207,228,234,241,242,244} Preliminary, and not altogether consistent, evidence hints that high doses of fish oil may produce benefits in bipolar disorder (more commonly known as manic-depressive illness), reducing risk of relapse and improving emotional state.^41,205,242 Other preliminary, and again not altogether consistent, evidence hints that fish oil might enhance the effectiveness of standard drugs (such as phenothiazines) for schizophrenia.^{48,148,169,170,193,247} Fish oil has also shown a bit of promise for borderline personality disorder.¹⁸⁰ In one study, DHA failed to augment the effectiveness of standard therapy for attention deficit disorder (ADD).⁸⁹ However, two studies that evaluated the potential benefits of fish oil combined with omega-6 fatty acids found some evidence of benefit for this condition.^88,194 Finally, one small trial found evidence that use of fish oil might decrease anger and aggressiveness in people with a history of aggressive behaviors, substance abuse, and problems with the law.²⁴³

Small studies also suggest that fish oil may be helpful in Raynaud’s phenomenon (a condition in which a person’s hands and feet show abnormal sensitivity to cold temperatures),^42,43 sickle-cell anemia,⁴⁵ and a form of kidney disease called IgA nephropathy.⁴⁷

According to some, but not all studies, fish oil may help treat the undesired weight loss often experienced by people with cancer.^181-182 In addition, highly preliminary evidence hints that DHA might enhance the effects of the cancer chemotherapy drug doxorubicin ¹⁵⁷ and decrease side effects of the chemotherapy drug irinotecan.¹⁵⁸

Use of fish oil by pregnant women might help prevent premature birth,^{184-185,208,236} although evidence is somewhat inconsistent. In addition, use of fish oil by pregnant women may support healthy brain function 183 and help prevent eczema and allergies in offspring.¹⁹⁵

Intriguing, but not yet at all reliable, evidence hints that fish oil, or its constituents, might be helpful for treating kidney stones or alleviating the symptoms of chronic fatigue syndrome, and reducing the risk of prostate cancer.^54,56,58,59 Results are inconsistent regarding whether the use of fish oil can decrease seizure frequency in people with epilepsy.^209,246

One study found that insulin metabolism in 278 young, overweight subjects improved on a calorie-restricted diet rich in fish oil from seafood or supplements compared to those on a diet low in fish oil, suggesting that fish oil may help delay the onset of diabetes in susceptible individuals.²⁵⁸ Fish oil has also been proposed as a treatment for many other conditions, including diabetic neuropathy,⁶⁰ allergies, and gout, but there has been little real scientific investigation of these uses.

Some, but not all, studies suggest that fish oil combined with omega-6 essential fatty acids may augment the effectiveness of calcium in the treatment of osteoporosis.^86,87 One promising, but highly preliminary, double-blind, placebo-controlled study suggests that the same combination therapy may improve symptoms of the severe neurological illness called Huntington’s disease.¹⁵⁵

Use of a fish oil product as part of a total parenteral nutrition regimen (intravenous feeding) may help speed recovery after major abdominal surgery.²³³

For several other conditions, the current balance of the evidence suggests that fish oil is not effective.

For example, despite widely publicized claims that fish oil helps asthma, most preliminary studies have failed to provide evidence that it is effective, and one study found that fish oil can actually worsen aspirin-related asthma.^{69-77,171,271} However, there is some evidence that use of fish oil could help prevent exercise-induced asthma in athletes.^196,212 And, in an interesting randomized, controlled trial with long-term follow-up, mothers who take fish-oil during late pregnancy reduced the risk of asthma in their children up to 16 years later.²⁶³

One study found that fish oil did not benefit the lung function of patients with cystic fibrosis.²⁵¹

Similarly, a 16-week, double-blind, placebo-controlled study of 167 individuals with recurrent migraine headaches found that fish oil did not significantly reduce headache frequency or severity.¹⁴⁹ Conflicting results have been seen in other, much smaller trials of fish oil for migraines.^172,173

One study found weak evidence that use of fish oil might decrease aggressive behavior in young girls (but, in this study, not in young boys).²¹³ Another study found benefit in developmental coordination disorder (a condition in which children suffer from lack of physical coordination as well as problems with learning and behavior).²¹⁴

Fish oil is also sometimes recommended for enhancing immunity in HIV infection. However, one 6-month, double-blind study found that a combination of the omega-3 fatty acids in fish oil plus the amino acid arginine was no more effective than placebo in improving immune function in people with HIV.⁷⁸ Fish oil, however, might help individuals with HIV gain weight.⁷⁹

In one large, randomized, controlled trial, diets rich in fish and omega-3 fatty acids from fish were associated with a significant reduction in the risk of developing colorectal cancer among men over a 22-year period.²⁵⁵ Another study provides preliminary evidence for the benefits of fish oil in reducing the risk of prostate cancer.⁵⁷ On balance, however, there is still relatively little evidence that the consumption of fish oil reduces cancer risk.²¹⁵

Preliminary studies have suggested that fish oil could help symptoms of multiple sclerosis; however, the largest double-blind study on the subject found no difference between people taking fish oil and those taking olive oil (used as a placebo).^80-84,216

Although one study found fish oil somewhat helpful in psoriasis,¹³³ a much larger study found no benefit.¹³⁴

DHA has been evaluated as a possible treatment for male infertility, but a double-blind trial of 28 men with impaired sperm activity found no benefit.⁸⁵

Combination therapy with GLA and fish oil has failed to prove effective for cyclic breast pain.¹⁸⁶

One study failed to find fish oil more effective than placebo for treating stress.²¹⁷ DHA has also been tried for slowing the progression of retinitis pigmentosa (a condition in which the retina gradually degenerates), but without much success.^210-211 In observational studies, people who happen to consume a diet rich in omega-3 fatty acids seem to lower their risk of age-related macular degeneration (the most common cause of blindness in the elderly). However, in the absence of randomized controlled trials, it is not possible to say whether or not it is omega-3 that produces this benefit.²⁶⁰

Studies of fish oil have failed to find it helpful for Alzheimer’s disease, whether for slowing its progression or improving symptoms.^230,240 And, one well-designed study failed to find any benefit of fish oil for enhancing memory and mental function in older adults without dementia over a 26 week period.²⁶⁵

Use of essential fatty acids in the omega-3 family has also shown some promise for the treatment of non-alcoholic fatty liver.^245,270

What Is the Scientific Evidence for Fish Oil?

Heart Disease Prevention

• Studies on fish or fish oil for preventing cardiovascular disease, slowing the progression of cardiovascular disease, and preventing heart-related death have returned somewhat contradictory results.^{106-125,150,156} A major review published in 2004 failed to find trustworthy evidence of benefit,²¹⁸ and a subsequent study actually found that use of fish oil increases risk of sudden death in people with stable heart disease.²¹⁹ A 2008 systematic review found that fish oil was associated with modestly reduced cardiac mortality, but not sudden cardiac death, in 11 studies totally over 32,000 patients. The reliability of these results, however, is limited by the inclusion of mostly low-to-moderate quality trials.²⁷² Though not entirely consistent, on balance the evidence does suggest that regulalry consuming oily fish or taking omega-3 fatty acid supplements can reduce the risk of cardiovascular events (eg, heart attacks) and deaths.²⁶¹ A 2009 review pooled data from 8 trials examining the effect of omega-3 fatty acids on prevention of cardiac death in almost 21,000 patients with coronary heart disease.²⁷⁴ This review separated patients into two general groups (those with previous myocardial infarction versus those with angina history) and found that omega-3 supplementation reduced risk of sudden cardiac death in patients with previous myocardial infarction, but increased risk in patients with angina. Though compelling, this finding may be limited since it was derived from a retrospective analysis of original data reorganized into subgroups.
• A gigantic study (over 18,000 participants) published in 2007 was widely described in the media as finally proving beyond a shadow of a doubt that fish oil helps prevent heart problems.²³⁹ Unfortunately, this study lacked a placebo group, and therefore failed to provide reliable evidence.
• As noted earlier, fish oil is hypothesized to exert several separate effects that act together to help protect the heart. The most important action of fish oil may be its apparent ability to reduce high triglyceride levels. Like cholesterol, triglycerides are a type of fat in the blood that tends to damage the arteries, leading to heart disease. According to most, though not all, studies, fish oil supplements can reduce triglycerides by as much as 25% to 30%.^{90-93,151,256} In a detailed review of 47 randomized trials, researchers concluded that fish oil is capable of significantly reducing triglyceride levels with no change in total cholesterol levels and only slight increases in HDL (“good”) cholesterol and LDL (“bad”) cholesterol.²⁶⁸ A slightly modified form of fish oil (ethyl-omega-3 fatty acids) has been approved by the FDA as a treatment for elevated triglycerides. However, in some studies, use of fish oil has markedly raised LDL cholesterol, which might offset some of the benefit. A 2009 review of 30 trials involving about 1,500 patients with type 2 diabetes demonstrated that marine-derived omega-3 polyunsaturated fatty acids (mean dose 2.4 g per day) lowered triglyceride levels about 15 mg/dL but increased LDL cholesterol by about 3 mg/dL after an average 24 weeks of treatment.²⁷⁵
• Stanols and sterols (or phytosterols) are naturally occurring substances found in various plants that can help to lower cholesterol in individuals with normal or mildly to moderately elevated levels. A study investigating the possible benefit of combining a phytosterol with fish oil found that together they significantly lowered total cholesterol, LDL-cholesterol and triglycerides, and raised HDL (“good”) cholesterol in subjects with undesirable cholesterol profiles.²⁵⁷
• Fish oil has been specifically studied for reducing triglyceride levels in people with diabetes, and it appears to do so safely and effectively.^3,262 It also seems to remain effective in individuals who are already using statin drugs to control lipid levels (both people with and without diabetes).^14,15,197 However, one study found that the standard drug gemfibrozil is more effective than fish oil for reducing triglycerides.⁹⁴
• Some but not all studies suggest that fish, fish oil, or EPA or DHA separately may additionally raise the level of HDL (“good”) cholesterol and possibly improve other aspects of cholesterol profile as well.^{96,97,151,164,165,197} This too should help prevent heart disease.
• Additionally, fish oil may help the heart by “thinning” the blood and by reducing blood levels of homocysteine,^98,176,190 although not all studies have found a positive effect.¹⁹⁸
• Studies contradict one another on whether fish oil can lower blood pressure,^{99-104,177,264} but on balance the supplement does seem to exert a modest positive effect.¹⁷⁴ A 6-week, double-blind, placebo-controlled study of 59 overweight men suggests that the DHA in fish oil, but not the EPA, is responsible for this benefit.¹⁰⁵
• Evidence is conflicting on whether fish oil helps prevent heart arrhythmias.^220-224,248 A large Italian trial involving almost 7,000 subjects found that fish oil may modestly reduce the risk of death or admission to the hospital for cardiovascular reasons in patients suffering from congestive heart failure.²⁶⁶
• Fish oil may slightly reduce heart rate.²²⁵ This effect could contribute to preventing heart attacks and other heart problems.

Rheumatoid Arthritis

• The results of numerous small double-blind trials indicate that omega-3 fatty acids in fish oil can help reduce the symptoms of rheumatoid arthritis.^{126,127,179,187} At least one small study suggests that it may help rheumatoid arthritis patients lower their dose of nonsteroidal anti-inflammatory medication (eg, ibuprofen).²⁵³ The benefits of the fish oil effect may be enhanced by a vegetarian diet.¹⁸⁷ Simultaneous supplementation with olive oil (about two teaspoons daily) may further increase the benefits.²²⁶ However, unlike some conventional treatments, fish oil probably does not slow the progression of rheumatoid arthritis.

Menstrual Pain

• Regular use of fish oil may reduce the pain of menstrual cramps.
• In a 4-month study of 42 young women aged 15 to 18, half the participants received a daily dose of 6 g of fish oil, providing 1,080 mg of EPA and 720 mg of DHA daily.¹²⁸ After 2 months, they were switched to placebo for another 2 months. The other group received the same treatments in reverse order. The results showed that these young women experienced significantly less menstrual pain while they were taking fish oil.
• Another double-blind study followed 78 women, who received either fish oil, seal oil, fish oil with vitamin B 12 (7.5 mcg daily), or placebo for three full menstrual periods.¹²⁹ Significant improvements were seen in all treatment groups, but the fish oil plus vitamin B 12 proved most effective, and its benefits continued for the longest time after treatment was stopped (3 months). The researchers offered no explanation why vitamin B 12 should be helpful.

Bipolar Disorder

• A 4-month, double-blind, placebo-controlled study of 30 individuals suggests that fish oil can enhance the effects of standard treatments for bipolar disorder, reducing risk of relapse and improving emotional state.¹³⁰ Eleven of the 14 individuals who took fish oil improved or remained well during the course of the study, while only 6 out of the 16 given placebo responded similarly.
• Another small study found that ethyl-EPA (a modified form of EPA) is helpful for the depressive phase of bipolar disease.²²⁷

Depression

• A 4-week, double-blind, placebo-controlled trial evaluated the potential benefits of fish oil in 20 individuals with depression.¹⁵⁴ All but one participant were also taking standard antidepressants and had been taking them for at least 3 months. By week 3, the level of depression had improved to a significantly greater extent in the fish oil group than in placebo group. Six of 10 participants given fish oil, but only one of 10 given placebo, showed at least a 50% reduction in depression scores by the end of the trial. (A reduction of this magnitude is considered a “cure.”)
• A double-blind, placebo-controlled study of 70 people who were still depressed despite standard therapy (such as SSRIs) found that additional treatment with ethyl-EPA (a modified form of EPA) improved symptoms.¹⁷⁵ Similar add-on benefits were also seen in other double-blind studies of ethyl-EPA or mixed essential fatty acids.^{192-193,228,250} However, one study failed to find benefit with fish-oil as an add-on treatment.²²⁹ Another double-blind study failed to find DHA alone helpful for depression.¹⁸⁸ A third relatively large placebo-controlled study found no benefit for fish oil in improving “mental well-being” among 320 older adults without a diagnosis of depression.²⁶⁷
• The effectiveness of fish oil supplementation in treating or preventing peripartum depression is, as of yet, unclear. A small preliminary study of women found that fish oil was significantly more effective than placebo at alleviating post-partum depression.²⁵² However, another small, placebo-controlled study was unable to show a benefit in women suffering from depression whether before or after delivery.²⁴⁹ In addition, a 2009 trial of 182 pregnant women with suspected low intake of docosahexaenoic acid (DHA) found that daily DHA supplementation (with or without arachidonic acid) did not reduce risk of postpartum depression compared to placebo.273

Raynaud’s Phenomenon

• In small, double-blind studies, fish oil has been found to reduce the severe finger and toe responses to cold temperatures that occur in Raynaud’s phenomenon.^131,132 However, these studies suggest that a higher than usual dosage must be used to get results, perhaps 12 g daily.

Osteoporosis

• There is some evidence that essential fatty acids may enhance the effectiveness of calcium in osteoporosis. In one study, 65 postmenopausal women were given calcium along with either placebo or a combination of omega-6 fatty acids (from evening primrose oil) and omega-3 fatty acids (from fish oil) for a period of 18 months. At the end of the study period, the group receiving essential fatty acids had higher bone density and fewer fractures than the placebo group.¹³⁵
• However, a 12-month, double-blind trial of 42 postmenopausal women found no benefit.¹³⁶
• The explanation for the discrepancy may lie in the differences between the women studied. The first study involved women living in nursing homes, while the second studied healthier women living on their own. The latter group of women may have been better nourished and already received enough essential fatty acids in their diet.

Lupus

• Lupus is a serious autoimmune disease that can cause numerous problems, including fatigue, joint pain, and kidney disease. One small, 34-week, double-blind, placebo-controlled crossover study compared placebo against daily doses of EPA (20 g) from fish oil.¹³⁷ A total of 17 individuals completed the trial. Of these, 14 showed improvement when taking EPA, while only 4 did so when treated with placebo. Another small study found similar benefits with fish oil over a 24-week period.¹⁹¹ However, two small studies failed to find fish oil helpful for lupus nephritis (kidney damage caused by lupus).^138,139

Attention Deficit and Hyperactivity Disorder (ADHD)

• Based on evidence that essential fatty acids are necessary for the proper development of brain function in growing children, EFAs have been tried for the treatment of ADHD and related conditions.
• A preliminary double-blind, placebo-controlled trial found some evidence that a supplement containing fish oil and evening primrose oil might improve ADHD symptoms.140 However, a high dropout rate makes the results of this trial somewhat unreliable. Another small study examined fish oil in children with ADHD who had thirst and skin problems. Benefits were seen with fish oil, but they also occurred with placebo and to about the same extent.¹⁹⁴
• In a double-blind, placebo-controlled trial of children already using stimulant therapy, addition of DHA for 4 months failed to further improve symptoms.¹⁴¹

Safety Issues

Fish oil appears to be generally safe. The most common problem is fishy burps. However, there are some safety concerns to consider.

For example, it has been suggested that some fish oil products contain excessive levels of toxic substances such as organochlorines and PCBs.¹⁶⁶ If possible, try to purchase fish oil products certified not to contain significant levels of these contaminants. Note: Various types of fish contain mercury, but this has not been a problem with fish oil supplements, according to reports on Consumerlab.com.

Fish oil has a mild blood-thinning effect;269 in one case report, it increased the effect of the blood-thinning medication warfarin (Coumadin).¹⁹⁹ Fish oil does not seem to cause bleeding problems when it is taken by itself ¹⁴² or with aspirin.¹⁴³ Nonetheless, people who are at risk of bleeding complications for any reason should consult a physician before taking fish oil.

Fish oil does not appear to raise blood sugar levels in people with diabetes.^144,145 Nonetheless, if you have diabetes, you should not take any supplement except on the advice of a physician.

Fish oil may modestly increase weight and lower total cholesterol and HDL (“good”) cholesterol levels.269 It may also raise the level of LDL (“bad”) cholesterol; however, this effect may be short-lived.^146,147

If you decide to use cod liver oil as your fish oil supplement, make sure you do not exceed the safe maximum intake of vitamin A and vitamin D. These vitamins are fat soluble, which means that excess amounts tend to build up in your body, possibly reaching toxic levels. The official maximum daily intake of vitamin A is 3,000 mcg for pregnant women as well as other adults. Look at the bottle label to determine how much vitamin A you are receiving. (It is less likely that you will get enough vitamin D to produce toxic effects.)

Interactions You Should Know About

If you are taking warfarin (Coumadin) or heparin, do not take fish oil except on the advice of a physician.

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5-HTP for Depression, Migraines, Weight Loss and Fibromyalgia Symptoms

Many antidepressant drugs work, at least in part, by raising serotonin levels. The supplement 5-hydroxytryptophan (5-HTP) has been tried in cases of depression for a similar reason: the body uses 5-HTP to make serotonin, so providing the body with 5-HTP might, therefore, raise serotonin levels.

As a supplement, 5-HTP has also been proposed for all the same uses as other antidepressants, including aiding weight loss, preventing migraine headaches, decreasing the discomfort of fibromyalgia, improving sleep quality, and reducing anxiety.

Sources

5-HTP is not found in foods to any appreciable extent. For use as a supplement, it is manufactured from the seeds of an African plant (Griffonia simplicifolia).

Therapeutic Dosages

A typical dosage of 5-HTP is 100 to 300 mg 3 times daily. Once 5-HTP starts to work, it may be possible to reduce the dosage significantly and still maintain good results.

Therapeutic Uses

The primary use of 5-HTP is for depression. Several small short-term studies have found that it may be as effective as standard antidepressant drugs.^1,2 Since standard antidepressants are also used for insomnia and anxiety, 5-HTP has also been suggested as a treatment for those conditions, but there is only very preliminary evidence as yet that it works.³

Similarly, antidepressant drugs are often used for migraine headaches. Some, but not all, studies suggest that regular use of 5-HTP may help reduce the frequency and severity of migraines, as well as help other types of headaches.^4-10 Additionally, preliminary evidence suggests that 5-HTP can reduce symptoms of fibromyalgia¹¹ and perhaps help you lose weight.^12-15

What Is the Scientific Evidence for 5-Hydroxytryptophan?

Depression

• Several small studies have compared 5-HTP to standard antidepressants.¹⁶ The best one was a 6-week study of 63 people given either 5-HTP (100 mg 3 times daily) or an antidepressant in the Prozac family (fluvoxamine, 50 mg 3 times daily).¹⁷ Researchers found equal benefit between the supplement and the drug. However, 5-HTP caused fewer and less severe side effects.

Migraine and Other Headaches

• There is some evidence that 5-HTP may help prevent migraines when taken at a dosage of 400 to 600 mg daily. Lower doses may not be effective.
• In a 6-month trial of 124 people, 5-HTP (600 mg daily) proved equally effective as the standard drug methysergide.¹⁸ The most dramatic benefits observed were reductions in the intensity and duration of migraines. Since methysergide has been proven better than placebo for migraine headaches in earlier studies, the study results provide meaningful, although not airtight, evidence that 5-HTP is also effective.
• Similarly good results were seen in another comparative study, using a different medication and 5-HTP (at a dose of 400 mg daily).¹⁹
• However, in one study, 5-HTP (up to 300 mg daily) was less effective than the drug propranolol.²⁰ Also, in a study involving children, 5-HTP failed to demonstrate benefit.²¹ Other studies that are sometimes quoted as evidence that 5-HTP is effective for migraines actually enrolled adults or children with many different types of headaches (including migraines).^22,23,24
• Putting all this evidence together, it appears likely that 5-HTP can help people with frequent migraine headaches if taken in sufficient doses, but further research needs to be done. In particular, we need a large double-blind study that compares 5-HTP against placebo over a period of several months.
• Finally, an 8-week, double-blind, placebo-controlled trial of 65 individuals (mostly women) with tension headaches found that 5-HTP at a dose of 100 mg 3 times daily did not significantly reduce the number of headaches experienced; however, it did reduce participants’ need to use other pain-relieving medications.²⁵

Obesity (Weight Loss)

• The drug fenfluramine was one member of the now infamous phen-fen treatment for weight loss. Although very successful, fenfluramine was later associated with damage to the valves of the heart and was removed from the market. Because fenfluramine raises serotonin levels, it seems reasonable to believe that other substances that affect serotonin might also be useful for weight reduction.
• Four small double-blind, placebo-controlled clinical trials examined whether 5-HTP can aid weight loss. The first, a double-blind crossover study, found that use of 5-HTP (at a daily dose of 8 mg per kilogram body weight) reduced caloric intake despite the fact that the 19 participants made no conscious effort to eat less.²⁶ Participants given placebo consumed about 2,300 calories per day, while those taking 5-HTP ate only 1,800 calories daily. Use of 5-HTP appeared to lead to a significantly enhanced sense of satiety after eating. Over the course of 5 weeks, women taking 5-HTP effortlessly lost more than 3 lbs.
• A follow-up study by the same research group enrolled 20 overweight women who were trying to lose weight.²⁷ Participants received either 5-HTP (900 mg per day) or placebo for two consecutive 6-week periods. During the first period, there was no dietary restriction, while during the second period participants were encouraged to follow a defined diet expected to lead to weight loss. Participants receiving placebo did not lose weight during either period. However, those receiving 5-HTP lost about 2% of their initial body weight during the no-diet period and an additional 3% while on the diet. Thus, a woman with an initial weight of 170 lbs lost about 3-1/2 lbs after 6 weeks of using 5-HTP without dieting and another 5 lbs while dieting. Once again, participants taking 5-HTP experienced quicker satiety.
• Similar benefits were seen in a double-blind study of 14 overweight women given 900 mg of 5-HTP daily.²⁸
• Finally, a double-blind, placebo-controlled study of 20 overweight individuals with adult-onset diabetes found that use of 5-HTP (750 mg per day) without intentional dieting resulted in about a 4-1/2 lb weight loss over a 2-week period.²⁹ Use of 5-HTP reduced carbohydrate intake by 75% and fat intake to a lesser extent.

Fibromyalgia

• Antidepressants are the primary conventional treatment for fibromyalgia, a little-understood disease characterized by aching, tender muscles, fatigue, and disturbed sleep. One study suggests that 5-HTP may be helpful as well. In this double-blind trial, 50 subjects with fibromyalgia were given either 100 mg of 5-HTP or placebo 3 times daily for a month.³⁰ Those receiving 5-HTP experienced significant improvements in all symptom categories, including pain, stiffness, sleep patterns, anxiety, and fatigue.

Anxiety

• An 8-week, double-blind, placebo-controlled study compared 5-HTP and the drug clomipramine in 45 individuals suffering from anxiety disorders.³¹ The results showed that 5-HTP was effective, but clomipramine was more effective.

Safety Issues

No significant adverse effects have been reported in clinical trials of 5-HTP. Side effects appear to be generally limited to short-term, mild digestive distress and possible allergic reactions.

One potential safety issue with 5-HTP involves an interaction with a medication used for Parkinson’s disease: carbidopa. Several reports suggest that the combination can create skin changes similar to those that occur in the disease scleroderma.^32,33,34

According to several reports, when dogs have consumed excessive amounts of 5-HTP, they developed signs of excess serotonin.³⁹ In humans, this so-called serotonin syndrome includes such symptoms as confusion, agitation, rapid heart rate, high blood pressure, muscle jerks, loss of coordination, sweating, shivering, and fever; rapid breathing, coma, and death are possible. Serotonin syndrome might also occur if 5-HTP is combined with drugs that raise serotonin levels, such as SSRIs (such as, Prozac), other antidepressants, or the pain medication tramadol.

There are some reasons for concern that 5-HTP could increase the risk of “infantile spasms” (technically, massive myoclonic seizure disorder) in developmentally disabled children.^35,40

Although safety in children has not been proven, children have been given 5-HTP in studies without any apparent harmful effects.^36,37,38 Safety in pregnant or nursing women and those with liver or kidney disease has not been established.

Peak X

One report in 1998 raised a potential safety concern with 5-HTP. Researchers discovered evidence of an unidentified substance called peak X in a limited number of 5-HTP products.⁴¹

Peak X has a frightening history involving a supplement related to 5-HTP: tryptophan. The body turns tryptophan into 5-HTP, and the two supplements have similar effects in the body. Until the late 1980s, tryptophan was widely used as a sleep aid. However, it was taken off the market when thousands of people using tryptophan developed a disabling and sometimes fatal blood disorder called eosinophilia myalgia. Peak X, introduced through a manufacturer’s mistake, is thought to have been the cause, although not all experts agree.^42-50

Despite this one report, it seems unlikely that 5-HTP could present the same risk as tryptophan.⁵¹ It is manufactured completely differently; peak X has not been seen again in 5-HTP samples, and no epidemic of eosinophilia myalgia has occurred with 5-HTP use.

Interactions You Should Know About

If you are taking:

• Prescription antidepressants (including SSRIs, MAO inhibitors, or tricyclics), the pain drug tramadol, or migraine drugs in the triptan family (such as sumatriptan): Do not take 5-HTP in addition, except on a physician’s advice.
• The Parkinson’s disease medication carbidopa: Taking 5-HTP at the same time might cause skin changes similar to those that develop in the disease scleroderma.

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St. John’s Wort for Mild to Moderate Depression

St. John’s wort is a common perennial herb of many branches and bright yellow flowers that grows wild in much of the world. Its name derives from the herb’s tendency to flower around the feast of St. John. (A wort simply means plant in Old English.) The species name perforatum derives from the watermarking of translucent dots that can be seen when the leaf is held up to the sun.

St. John’s wort has a long history of use in treating emotional disorders. During the Middle Ages, St. John’s wort was popular for “casting out demons.” In the 1800s, the herb was classified as a nervine, or a treatment for “nervous disorders.” When pharmaceutical antidepressants were invented, German researchers began to look for similar properties in St. John’s wort.

What Is St. John’s Wort Used for Today?

Today, St. John’s wort is a widely used treatment for depression in Germany, other parts of Europe, and the United States. The evidence-base for its use approaches that of many modern prescription drugs at the time of their first approval.

Most studies of St. John’s wort have evaluated individuals with major depression of mild to moderate intensity. This contradictory-sounding language indicates that the level of depression is more severe than simply feeling “blue.” However, it is not as severe as the most severe forms of depression. Typical symptoms include depressed mood, lack of energy, sleep problems, anxiety, appetite disturbance, difficulty concentrating, and poor stress tolerance. Irritability can also be a sign of depression.

Taken as a whole, research suggests that St. John’s wort is more effective than placebo and approximately as effective as standard drugs. Furthermore, St. John’s wort appears to cause fewer side effects than many antidepressants. However, the herb does present one significant safety risk: it interacts harmfully with a great many standard medications. (See Safety Issues for details.)

St. John’s wort has also shown promise for treatment of severe major depression.^107,126 Note: St. John’s wort alone should never be relied on for the treatment of severe depression. If you or a loved one feels suicidal, unable to cope with daily life, paralyzed by anxiety, incapable of getting out of bed, unable to sleep, or uninterested in eating, see a physician at once. Professional care may be lifesaving.

Besides depression, St. John’s wort has also been tried for many other conditions in which prescription antidepressants are thought useful, such as attention deficit disorder,¹³¹ anxiety, insomnia,¹⁵ menopausal symptoms,²⁰ premenstrual syndrome (PMS),^19,102 seasonal affective disorder (SAD),^98,99 and social phobia.¹⁰³ However, there is as yet no convincing evidence that it offers any benefit for these conditions. One substantial double-blind study did find St. John’s wort potentially helpful for somatoform disorders (commonly called psychosomatic illnesses).¹⁰⁴

Standard antidepressants are also often used for diabetic neuropathy and other forms of neuropathy (nerve pain). However, a small double-blind, placebo-controlled trial failed to find St. John’s wort effective for this purpose.¹⁶ Another study failed to find St. John’s wort helpful for obsessive-compulsive disorder.¹¹⁵

St. John’s wort contains, among other ingredients, the substances hypericin and hyperforin. Early reports suggested that St. John’s wort or synthetic hypericin might be useful against viruses such as HIV, but these haven’t panned out.¹⁷ However, there is some evidence hyperforin may be able to fight certain bacteria, including some that are resistant to antibiotics.¹⁸ Note: This evidence is far too preliminary to count St. John’s wort as an effective antibiotic.

Based on weak evidence that hypericin might have anti-inflammatory properties, St. John’s wort cream has been tried as a treatment for eczema, with some promising results.¹⁰⁰

One interesting double-blind study evaluated a combination therapy containing St. John’s wort and black cohosh in 301 women with general menopausal symptoms as well as depression.¹¹⁶ The results showed that use of the combination treatment was significantly more effective than placebo for both problems.

In a small placebo-controlled trial, hypericin extract showed no benefit for burning mouth syndrome, a poorly understood condition in which a person experiences ongoing moderate to severe pain in the tongue and/or mouth.¹²⁹

What Is the Scientific Evidence for St. John’s Wort?

Depression

There have been two main kinds of studies: those that compared St. John’s wort to placebo, and others that compared it to prescription antidepressants. A 2008 detailed review of 29 randomized, placebo controlled trials found that St. Johns wort was consistently more effective than placebo and equally effective to standard antidepressants.¹³³

St. John’s Wort Versus Placebo

• Studies of St. John’s wort (and other antidepressants) use a set of questions called the Hamilton Depression Index (HAM-D). This scale rates the extent of depression, with higher numbers indicating more serious symptoms.
• Double-blind, placebo-controlled trials involving a total of more than 1,500 participants with major depression of mild to moderate severity have generally found that use of St. John’s wort can significantly reduce HAM-D scores as compared to placebo.^{21-28,89,105,123} In addition, continued treatment with St. Johns Wort over 6 months may be effective at preventing a relapse of moderate depression in patients who recover from an initial acute episode.¹³²
• For example, in a 6-week trial, 375 individuals with average 17-item HAM-D scores of about 22 (indicating major depression of moderate severity) were given either St. John’s wort or placebo.⁸⁹ Individuals taking St. John’s wort showed significantly greater improvement than those taking placebo.
• Three double-blind, placebo-controlled trials evaluating individuals with a similar level of depression have failed to find St. John’s wort more effective than placebo.^27,85,106 However, three studies cannot overturn a body of positive research. Keep in mind that 35% of double-blind studies involving pharmaceutical antidepressants have also failed to find the active agent significantly more effective than placebo.⁸⁵ As if to illustrate this, in two of the three studies in which St. John’s wort failed to prove effective, a conventional drug (Zoloft in one case, Prozac in the other) also failed to prove effective. The reason for these negative outcomes is not that Zoloft or Prozac does not work. Rather, statistical effects can easily hide the benefits of a drug, especially in a condition like depression where there is as a high placebo effect and no really precise method of measuring symptoms. Thus, unless a whole series of studies find St. John’s wort ineffective, especially trials in which a comparison drug treatment does prove effective, St. John’s wort should still be regarded as probably effective for major depression of mild to moderate severity.

St. John’s Wort Versus Medications

• At least 8 double-blind trials enrolling a total of more than 1,200 people have compared St. John’s wort to fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil) or sertraline (Zoloft).^{31-33,90,91,107,108,117-118} In all of these studies, the herb proved as effective as the drug and generally caused fewer side effects.
• In the largest of these trials, a 6-week study of 388 people with major depression of mild-to-moderate severity, St. John’s wort proved equally effective as the drug citalopram (Celexa) and more effective than placebo.¹¹⁸ Additionally, Celexa caused a significantly higher rate of side effects than St. John’s wort. There were also significantly more side effects in the placebo group than in the St. John’s wort group—presumably because treatment of depression reduces physical symptoms of psychological origin.
• St. John’s wort has also been compared to older antidepressants, with generally favorable results.^34-38

How Does St. John’s Wort Work for Depression?

• Like pharmaceutical antidepressants, St. John’s wort is thought to raise levels of neurotransmitters in the brain, such as serotonin, norepinephrine, and dopamine.^6,7
• The active ingredient of St. John’s wort is not known. Extracts of St. John’s wort are most often standardized to the substance hypericin, which has led to the widespread misconception that hypericin is the active ingredient. However, there is no evidence that hypericin itself is an antidepressant. Another ingredient of St. John’s wort named hyperforin has shown considerable promise as the most important ingredient. Hyperforin was first identified as a constituent of Hypericum perforatum in 1971 by Russian researchers, but it was incorrectly believed to be too unstable to play a major role in the herb’s action.¹ However, subsequent evidence corrected this view. It now appears that standard St. John’s wort extract contains about 1% to 6% hyperforin.² Evidence from animal and human studies suggests that it is the hyperforin in St. John’s wort that raises the levels of neurotransmitters.^8-10 Nonetheless, there may be other active ingredients in St. John’s wort also at work.^11,12 In fact, 2 double-blind trials using a form of St. John’s wort with low hyperforin content found it effective.^13,14 The bottom line remains that more research is necessary to discover just how St. John’s wort acts against depression.

Polyneuropathy

• A double-blind, placebo-controlled trial of 54 people with diabetic neuropathy or other forms of neuropathy (pain, numbness and/or tingling caused by injury to nerves) did not find St. John’s wort effective for this purpose.⁴⁰

Dosage

The typical dosage of St. John’s wort is 300 mg 3 times a day of an extract standardized to contain 0.3% hypericin. Some products are standardized to hyperforin content (usually 2% to 3%) instead of hypericin. These are usually taken at the same dosage. Two studies found benefits with a single daily dose of 900 mg.^118-119

Yet another form of St. John’s wort has shown effectiveness in double-blind studies. This form contains little hyperforin and is taken at a dose of 250 mg twice daily.^41,42 There is some evidence that this form of St. John’s wort may be less likely to interact with medications. (See Drug Interactions.)

If the herb bothers your stomach, take it with food.

Remember that the full effect takes 4 weeks to develop. Don’t give up too soon!

Safety Issues

St. John’s wort taken alone usually does not cause immediate side effects. In a study designed to look for side effects, 3,250 people took St. John’s wort for 4 weeks.⁴³ Overall, about 2.4% reported problems. The most common complaints were mild stomach discomfort (0.6%), allergic reactions—primarily rash—(0.5%), tiredness (0.4%), and restlessness (0.3%). Another study followed 313 individuals treated with St. John’s wort for 1 year.⁴⁴ The results showed a similarly low incidence of adverse effects.

In the extensive German experience with St. John’s wort as a treatment for depression, there have been no published reports of serious adverse consequences from taking the herb alone.⁴⁵ Animal studies involving enormous doses of St. John’s wort extracts for 26 weeks have not shown any serious effects.⁴⁶

However, there are a number of potential safety risks with St. John’s wort that should be considered. These are outlined in the following sections.

Photosensitivity

Cows and sheep grazing on St. John’s wort have sometimes developed severe and even fatal sensitivity to the sun. In one study, highly sun-sensitive people were given twice the normal dose of the herb.⁴⁷ The results showed a mild but measurable increase in reaction to ultraviolet radiation. Another trial found that a one-time dose of St. John’s wort containing 2 or 6 times the normal daily dose did not cause an increased tendency to burn, nor did 7 days of treatment at the normal dose.⁸³ However, there is a case report of severe and unexpected burning in an individual who used St. John’s wort and then received ultraviolet therapy for psoriasis.⁴⁸ In addition, two individuals using topical St. John’s wort experienced severe reactions to sun exposure.⁸⁴

The morals of the story are as follows: if you are especially sensitive to the sun, don’t exceed the recommended dose of St. John’s wort, and continue to take your usual precautions against burning. If you are receiving UV treatment, do not use St. John’s wort at all; and if you apply St. John’s wort to your skin, keep that part of your body away from the sun.

In addition, you might get into problems if you combine St. John’s wort with other medications that cause increased sun sensitivity, such as sulfa drugs and the anti-inflammatory medication piroxicam (Feldene). The medications omeprazole (Prilosec) and lansoprazole (Prevacid) may also increase the tendency of St. John’s wort to cause photosensitivity.⁴⁹

Finally, a report suggests that regular use of St. John’s wort might also increase the risk of sun-induced cataracts.⁵⁰ While this is preliminary information, it may make sense to wear sunglasses when outdoors if you are taking this herb on a long-term basis.

Drug Interactions

Herbal experts have warned for some time that combining St. John’s wort with drugs in the Prozac family (SSRIs) might raise serotonin too much and cause a number of serious problems. Recently, case reports of such events have begun to trickle in.^51-53 This is a potentially serious risk. Do not combine St. John’s wort with prescription antidepressants except on the specific advice of a physician. Since some antidepressants, such as Prozac, linger in the blood for quite some time, you also need to exercise caution when switching from a drug to St. John’s wort.

Antimigraine drugs in the triptan family (such as sumatriptan, or Imitrex) and the pain-killing drug tramadol also raise serotonin levels and might interact similarly with St. John’s wort.^54,55

However, perhaps the biggest concern with St. John’s wort is that it appears to decrease the effectiveness of numerous medications, including protease inhibitors and reverse transcriptase inhibitors (for HIV infection), cyclosporine and tacrolimus (for organ transplants), digoxin (for heart disease), statin drugs (used for high cholesterol), warfarin (Coumadin) (a blood thinner), chemotherapy drugs, oral contraceptives, tricyclic antidepressants, protein pump inhibitors (like Prilosec), atypical antipsychotics like olanzapine or clozapine (for schizophrenia), anesthetics, and the new heart disease drug ivabradine.^{56-67,80,82,87,88,92,93,95,101,109-113,124,125,127,128} In fact, there are theoretical reasons to believe that this herb might reduce the effectiveness or otherwise interact with about 50% of all medications.114 Furthermore, suppose you are taking St. John’s wort while your physician is adjusting the dosage of one of your medications to obtain an optimum balance of efficacy and side effects. A problem may then occur if you subsequently stop taking the herb: blood levels of the drug may then rise, with potentially dangerous consequences.

Note that these proposed interactions are not purely academic: they could lead to catastrophic consequences. Indeed, St. John’s wort appears to have caused several cases of heart, kidney, and liver transplant rejection by interfering with the action of cyclosporine.

The herb also appears to decrease the effectiveness of oral contraceptives¹²⁰ and by doing so is thought to have caused unwanted pregnancies.^68,88

On a less dramatic level, one study showed that among people taking a cholesterol-lowering medication in the statin family, use of St. John’s wort caused cholesterol levels to rise.¹²⁷ (The same would be expected to occur if you are using red yeast rice to treat high cholesterol, as red yeast rice supplies naturally-occurring statin drugs.)

Finally, some people with HIV take St. John’s wort in the false belief that the herb will fight AIDS. The unintended result may be to reduce the potency of standard anti-HIV drugs.

There is some evidence that low-hyperforin St. John’s wort may have less potential for drug interactions than other forms of St. John’s wort.^121-122,125 Nonetheless, we recommend that people taking any oral or injected medication that is critical to their health or wellbeing should entirely avoid using any form of St. John’s wort until more is known; if you are already taking the herb, you should not stop taking it until you can simultaneously have your drug levels monitored. On general principles, we also advise avoid using the herb prior to undergoing general anesthesia.

Safety in Special Circumstances

One animal study found no ill effects on the offspring of pregnant mice.⁶⁹ However, these findings alone are not sufficient to establish St. John’s wort as safe for use during pregnancy. Furthermore, the St. John’s wort constituent hypericin can accumulate in the nucleus of cells and directly bind to DNA.⁷⁰ For this reason, pregnant or nursing women should avoid St. John’s wort. Furthermore, safety for use by young children or people with severe liver or kidney disease has not been established.

Like other antidepressants, case reports suggest that St. John’s wort can cause episodes of mania in individuals with bipolar disorder (manic-depressive disease).^71,72

There is also one report of St. John’s wort causing temporary psychosis in a person with Alzheimer’s disease.⁷⁹

Other Concerns

Certain foods contain a substance named tyramine. These foods include aged cheeses, aged or cured meat, sauerkraut, soy sauce, other soy condiments, beer (especially beer on tap). and wine. Drugs in the MAO inhibitor family interact adversely with tyramine, causing severe side effects such as high blood pressure, rapid heart rate, and delirium. One case report suggests that St. John’s might present this risk as well.⁹⁶ However, other studies suggest that normal doses of St. John’s should not cause MAO-like effects.^4,5,97 Until this issue is sorted out, we recommend that individuals taking St. John’s wort avoid tyramine-containing foods. Since MAO inhibitors react adversely with stimulant drugs such as Ritalin, ephedrine (found in the herb ephedra), and caffeine, we also recommend that you avoid combining St. John’s wort with them.

One small study suggests that high doses of St. John’s wort might slightly impair mental function.⁷³

One case report associates use of St. John’s wort with hair loss.⁷⁴ The authors note that standard antidepressants may also cause hair loss at times.

One study raised questions about possible antifertility effects of St. John’s wort. When high concentrations of St. John’s wort were placed in a test tube with hamster sperm and ova, the sperm were damaged and less able to penetrate the ova.⁷⁵ However, since it is unlikely that this much St. John’s wort can actually come in contact with sperm and ova when they are in the body rather than in a test tube, these results may not be meaningful in real life.

In one reported case, St. John’s Wort may have interacted with the menopause drug tibolone to produce severe liver damage.¹³⁰

Transitioning from Medications to St. John’s Wort

If you are taking a prescription drug for mild to moderate depression, switching to St. John’s wort may be a reasonable idea if you would prefer taking an herb. To avoid overlapping treatments, the safest approach is to stop taking the drug and allow it to wash out of your system before starting St. John’s wort. Consult with your doctor on how much time is necessary.

However, if you are taking medication for severe depression, switching over to St. John’s wort is not a good idea. The herb probably won’t work well enough, and you may sink into a dangerous depression.

Interactions You Should Know About

If you are taking:

• Antidepressant drugs, including MAO inhibitors, SSRIs, and tricyclics, or possibly the drugs tramadol or sumatriptan (Imitrex): Do not take St. John’s wort at the same time. Actually, you need to let the medication flush out of your system for a while (perhaps weeks, depending on the drug) before you start the herb.
• Digoxin, cyclosporine and tacrolimus, protease inhibitors or reverse transcriptase inhibitors, oral contraceptives, tricyclic antidepressants, warfarin (Coumadin), statin drugs, theophylline, chemotherapy drugs, newer antipsychotic medications (such as olanzapine and clozapine), anesthetics, or, indeed, any critical medication: St. John’s wort might cause the drug to be less effective. Furthermore, if you are already taking St. John’s wort and your physician adjusts your medication dosage to achieve proper blood levels, suddenly stopping St. John’s wort could cause the level of the drug in your body to rebound to dangerously high levels.
• Medications that cause sun sensitivity such as sulfa drugs and the anti-inflammatory medication piroxicam (Feldene), as well as omeprazole (Prilosec) or lansoprazole (Prevacid): Keep in mind that St. John’s wort might have an additive effect.
• Stimulant drugs or herbs such as Ritalin, caffeine, or ephedrine ( ephedra): It is possible that St. John’s wort might interact adversely with them.

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